The Case for Brachytherapy: An Interview with Michael F. Sarosdy, MD

Having performed more than 1,200 brachytherapy treatments since 1996 and conducting research in this field, urologic oncologist Michael F. Sarosdy, MD, founder of South Texas Urology & Urologic Oncology, in San Antonio, is convinced that this is a far better choice than surgery for most men withprostate cancer, regardless of the patient’s age or tumor characteristics.

Brachytherapy is touted as the safest and least expensive of the three main treatments for prostate cancer, which also include radical prostatectomy and external beam radiation therapy (EBRT). Does brachytherapy deserve this reputation?

Dr. Sarosdy:Absolutely. It’s very cost-effective and it has the least impact on day-to-day function in terms of treatment delivery. It’s a one-time outpatient treatment that requires about one hour in the operating room, under anesthesia, to implant the seeds, which are little titanium shells that contain radioactive material. The patient can quite literally return to work the next day.

Brachytherapy has become more sophisticated and polished in the 25 years since it was first used for prostate cancer. Physics planning software, technique, and ultrasound imaging have improved, and we’ve learned how to do the treatment more effectively and more safely. And now, some physicians are using real-time physics planning, where you do it right in the operating room instead of planning ahead of time and then trying to match up the image in the operating room with the image that was done for the preplan. This does makes the procedure take a little longer.

How often is brachytherapy used relative to other options?

Dr. Sarosdy:Brachytherapy has a very well-defined place in the treatment of prostate cancer. Over the past 10 years or so, there has been less brachytherapy done, because while robotic surgery has not been shown to be superior to open surgery, patients are less reluctant to undergo surgery with a robotic and laparoscopic technique. They feel less threatened by it, even though the fact is that it’s already been shown to have no higher cure rate. In fact, there are more frequent urinary complications with the robotic compared to open surgery.

Is there a clearly defined patient for brachytherapy compared with prostatectomy?

Dr. Sarosdy:No. Brachytherapy can be done in any patient with prostate cancer. There’s not one patient that’s better treated with it than another. It’s really suitable for any patient who desires to avoid surgery and external radiation and to undergo a relatively easy-to-deliver treatment that’s going to have less impact, both long-term and short-term, on his lifestyle.

The other reason that we’ve seen a decrease in the number of brachytherapy cases is that physicians—both radiation oncologists and urologists—have made a shift toward IMRT [intensity-modulated radiation therapy], for no other reason than that it’s reimbursed at substantially higher rates than brachytherapy. The cost for IMRT is about three to four times higher than the cost for brachytherapy, with no improvement in outcomes. Also, IMRT treatment delivery is somewhat onerous compared to brachytherapy: You have to go for nine weeks, Monday to Friday, to have the IMRT delivered, as opposed to one day for brachytherapy.

And there’s no data to support the idea that younger men should have surgery over brachytherapy or even IMRT. They actually have longer to live with the complications of surgery than older men—they have a longer time to be incontinent and impotent.

Kibel and colleagues reported inThe Journal of Urology(published online February 15, 2012) that among more than 10,000 men undergoing radical prostatectomy, EBRT, or brachytherapy, brachytherapy was associated with decreased overall survival but not with prostate cancer–specific mortality compared with radical prostatectomy. (EBRT was also associated with decreased overall survival but increased prostate cancer–specific mortality.) Did you find anything remarkable about these results?

Dr. Sarosdy:Oh, I don’t think so. You can explain a lot of those findings. For instance, the overall survival was better with radical prostatectomy, but we tend to do that procedure in younger and healthier patients, and we tend to send patients who are older and have other morbidity issues for radiation therapy. That translates to what you see there in the difference in overall survival, because that’s not related to cancer-specific survival.

Jay P. Ciezki, MD, from the Cleveland Clinic presented findings at the 2012 Genitourinary Cancers Symposium: He and his team looked at 16 years’ worth of claims-based data for 100,000 men with prostate cancer, and found that brachytherapy patients experienced the least toxicity requiring intervention, at 3.4%. For surgery it was nearly double that—6.7% of patients having prostatectomy had some problems with their genitourinary organs afterwards, as did 7% of men treated with external radiation.

Brachytherapy usually is not recommended for high-risk patients, but a large study by Shen et al. (International Journal of Radiation Oncology, Biology, Physics;published online January 21, 2012) has found that brachytherapy alone or in combination with EBRT significantly reduced prostate cancer–specific mortality compared with EBRT alone. Does this finding surprise you?

Dr. Sarosdy:Not at all! There’s more and more data coming out that brachytherapy doesn’t need to be restricted to the low-risk patients; that it’s just as effective in high-risk patients. And we presented that data to the American Urological Association ourselves in 2007.

Brachytherapy is one of your main areas of clinical investigation, and in 2007 you concluded that testosterone replacement therapy could be used with caution and close follow-up after prostate brachytherapy. (Cancer2007;109:536-541). What made this practice controversial?

Dr. Sarosdy:There was somewhat of a hysteria about giving testosterone to men who had been treated for prostate cancer since we know that testosterone fuels prostate cancer. And there had been two very, very small reports of testosterone therapy in men who had undergone radical prostatectomy, and then my report was one of a much larger series of men who in fact still had the prostate gland in place because they had received brachytherapy. That stimulated a tremendous amount of retrospective data analysis around the country, and several additional large papers have come out now, both after surgery and after radiation, showing similar outcomes. Particularly since we have PSA as a marker, we have something that’s sensitive and accurate to utilize in following these patients that we might need to treat for hypogonadism.

When you meet with a patient, do you go in with an assumption that you’re going to recommend brachytherapy unless something specifically contraindicates that?

Dr. Sarosdy:I come from a neutral stance, but the bottom line is that any rational analysis of treatment-related side effects compared to the efficacy of different forms of treatment would lead a thinking individual away from surgery to brachytherapy or to IMRT, for that matter. There is absolutely no proven superiority of surgery over the other treatments, and in fact the side effects are greater.

You also concentrate heavily on advanced bladder cancer. Does brachytherapy have a role there?

Dr. Sarosdy:There was some brachytherapy done inEurope in the 1970s for bladder cancer using an open technique: They opened up the bladder and implanted seeds, and some efficacy was demonstrated. The problem with bladder cancer is that it tends to be a much faster-growing tumor than prostate, so it doesn’t lend itself as well to slow delivery of radioactivity.